Bad news MDs a turnoff

Remember that old line: "Look doc, give it to me straight."  Conventional wisdom in medical care says physicians should speak plainly to their patients so they can make informed decisions about their medical care.  But a study published last week in the journal JAMA Oncology says people don't like doctors who are too frank with unpleasant news. Patients overwhelmingly prefer doctors who shade the truth and present a sunny prognosis - even when there's little be sunny about.  

That's the main conclusion from a study by Dr. Eduardo Brurera (formerly of Edmonton) and colleagues at MD Anderson Cancer Center in Texas.  The researchers showed 100 patients with advanced cancer two videos - each four minutes in length.  Each video featured a professional actor who played a doctor discussing treatment with a patient with advanced cancer.  In the optimistic video, the doctor talks mainly about the possibility of future treatment.  In the pessimistic video, the doctor tells the patient there are no further treatment options available.  In each video, the 'doctor' made the same five empathic statements.  

By a margin of close to three to one, the patients with cancer who watched the videos preferred the optimistic doc. The researchers didn't just ask which actor the patients preferred.  They measured the patients' impression of how compassionate both doctors appeared to be.  It was uncanny; compared to the pessimistic doc, patients believed that the physician in the more optimistic video was more compassionate and more trustworthy.

The researchers took good care with the study design to factor out things that might have biased the patients who watched the videos.  Because the patients watched both videos, they couldn't have the same actor appear as the doctor in each one.  So, they hired two different actors with similar physical characteristics (white, male, middle aged).  The actors were directed by the same director to perform the same way in each video.  Three observers independently watched both videos with the sound off to ensure the facial expressions and body posture of the actors who played the doctors were similar; they also listened to the soundtrack minus the video to ensure there was no bias in the voices of the actors. 

The study is important because it's probably the first randomized clinical study that demonstrates that it's not just how doctors communicate but what they communicate that determines whether or not patients find them compassionate and trustworthy. It's well known that doctors are reluctant to give bad news to patients.

The study is also important because of its implications for our ethical obligation to communicate honestly with patients. In part, many of us aren't well trained in how to do it.  You can give doctors better schooling in how to break bad news. But this study makes it clear that the inherent badness of the news means our patients may not like us for telling it like it is

I have had many opportunities to break bad news in the ER.  It's part of the job.  There can be nothing more difficult than telling a loved one that a partner, a father, a mother, or (heaven forbid) a child has died.  I can remember one instance in which I told a daughter late one night that her father had passed away. Months later, she spoke quite eloquently about how badly I had done it.  Like many of my colleagues, I was untrained in giving bad news to family members.  I think health professionals approach these situations thinking of their own distress and not that of the surviving family members. I suppose this study gives me some comfort in knowing that even the most compassionate approach can't always undo the devastating impact of the news.

You have to be up to the task on very short notice.  There are times when I meet the challenge of breaking bad news head on.  There are other times when I shade the truth to give the wiggle room that allow the patient to assume a more optimistic prognosis than is warranted by the facts. There are still other occasions in which I say little and leave it to others to do the dirty work of truth telling.

This study demonstrates that if we have to break bad news to patients, there's a good chance they won't like us for that.  Knowing that helps explain why it is that doctors put off or even fail to give patients the straight goods. The system has to put more effort into training health professionals to tell the truth instead of shading it in false optimism.  

If patients, families and other substitute decision makers don't hear what they need to hear, how can they make appropriate treatment decisions like whether to undergo another round of chemo, sign a do not resuscitate form, or a say yes or no to a feeding tube?